Hospital Beds Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for hospital beds HCPCS codes E0260, E0261, and E0303 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 14.71%. The top 10 reasons for claim denials are as follows:
| Rank | Reason | Percent |
|---|---|---|
| 1. | The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212 . |
38.96% |
| 2. | The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) . |
19.48% |
| 3. | No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8 |
10.39% |
| 4. | Medical records do not support that the beneficiary requires frequent changes in body position and/or has an immediate need for a change in body position. | 9.09% |
| 5. | Medical records do not support that one of the four criteria for a fixed height hospital bed have been met. | 6.49% |
| 6. | The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9 |
6.49% |
| 7. | The standard written order (SWO) is missing a description of the item. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2 and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). |
3.90% |
| 8. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 2.60% |
| 9. | The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4 |
1.30% |
| 10. | The supply or accessory is denied as the base equipment is denied. Refer to applicable Local Coverage Determination/Policy Article. | 1.30% |
*The total percentage will be greater than 100% because some claims were denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to represent an overall error rate for the HCPCS code or policy under medical record review.
Resources:
Updated: February 2, 2024
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